Solving the Problem of Organ Donation

By Angela Griffith

6,570 Americans die every year waiting for a donor organ.  Says Johns Hopkins surgeon Dr. Andrew Cameron, “There just aren’t enough organ donors to go around.  That’s not a medical problem.  That’s a social problem.”  Though 95% of people support organ donation, only 40% are registered organ donors.  For the over 123,000 people on the waiting list, there just aren’t enough donor organs to go around.

This issue can be addressed within a Cause Map, a visual root cause analysis.  The first step is to capture the “what”, “when”, and “where of the incident, as well as the impact to the goals.  In this case, the problem is lack of donor organs available, causing patient deaths.  Though the problem exists everywhere, the focus of this blog will be on ongoing organ shortage in the United States.  Important differences in the United States related to organ donation are that only 40% of Americans are registered organ donors (despite widespread public support), and that there is no central registry of organ donors within the United States.  (Organ registries are typically state-run.)

The large number of deaths resulting from inadequate donor organs is an impact to the patient safety goal.  The delay in receipt of organs can be considered both an impact to the patient services and schedule/operations goal.  The lack of available organs can be considered an impact to the property goal.

To develop the cause-and-effect relationships that led to the impacted goals, we ask “why” questions.  In this case, the patient deaths result from the need for donor organs due to disease or injury, and the delay in receipt of organs.  The delay in receipt of organs is due to a lack of available organs.  Millions of Americans die every year, and while not all organs are acceptable for transplant, more than one organ can often be used from donors, resulting in multiple lives saved from each donor.

In an interesting cause-and-effect result, increased traffic safety has resulted in fewer fatal traffic accidents of young, healthy people, which has led to a decrease in available donor organs.  Of course there is no effort to try and increase organ donation by stopping the decrease of deaths of young people.

The shortage of donors from people who are eligible (upon death or brain death) result from not signing up for the organ donation registry and/or from a family not choosing to donate organs.  There are multiple reasons suggested for people not choosing to register or donate organs.  To solve the problem, companies are working on increasing the number of donors.  Dr. Cameron coordinated with Facebook to allow users to register as organ donors and saw the number of organ donors go up “22 fold”.  Says Dr. Cameron, “That’s proof that we can move the needle.”  The startup Organize is “building a portfolio of technology that makes it easier for people to demonstrate their desire to be an organ donor.”  The company hopes that it will improve organ donation to the point that it puts itself out of business in five years.

To view the overview of the organ donation problem and solutions, click on “Download PDF” above.  As discussed in a previous blog, work is also being done to increase the number of organs that are acceptable for donation (in this case with kidneys).

Scientists Moving a Lab Find Forgotten Smallpox

By Kim Smiley

On July 1, 2014, vials marked “variola”, the virus that causes smallpox, were found when a fridge was being cleaned out as part of the effort to move a National Institutes of Health campus to a new location. The vials were immediately secured and a CDC team was dispatched to retrieve the vials. No exposure to smallpox is suspected, but the discovery is still alarming. There are only two heavily secured locations where smallpox is supposed to exist in the world so the fact that vials of a dangerous virus were just sitting forgotten in a fridge has raised many issues that that should be investigated.

This issue can be analyzed by building a Cause Map, a visual root cause analysis method.  To build a Cause Map, the problem is first defined by identifying impacts to the overall goals and then “why” questions are asked to lay out all the causes that contributed to an issue to show the cause-and-effect relationships.  For this example, the safety goal was impacted because there was potential for a smallpox outbreak.  This would be the first box on the Cause Map and more boxes would be added by asking “why”.

So “why” was there potential for a smallpox outbreak?  This occurred because there was a potential for people to be exposed to the smallpox virus and the population has little to no immunity to smallpox.  There was potential for exposure to smallpox because “lost” vials of smallpox were in a fridge in an unsecured lab.  The vials, which were created in 1954, appear to have been in the fridge a long time and somewhere along the way, their presence was forgotten.  Smallpox can survive in refrigeration for a long time and testing has shown that the virus was still viable.  The general population has little immunity to smallpox.  The last smallpox case in the United States was in 1949 and the US stopped vaccinating for smallpox in 1972.

The final step of the Cause Mapping process is to use the Cause Map to develop and implement solutions to  reduce the risk of a similar problem occurring in the future.  In this example, the immediate problem was addressed by moving the vials to a secured lab.  Once scientists are done studying the vials, the contents and all traces of the virus will be destroyed.  Longer-term solutions will likely include ensuring that all  government laboratory storerooms are inventoried to ensure that no other potentially dangerous vials have been “lost”.  Inventory procedures should also be reviewed to ensure they are adequate.

To me, the most worrisome part of this issue is that the vials were only discovered because workers were moving the lab to a new location. It naturally raises questions about what else might be out there and how frequently inventory is happening, or not happening as the case may be.   Investigation into this incident has already uncovered a number of other vials filled with potentially dangerous specimens in the same storage facility.   If any other potentially dangerous vials are “lost” in other locations, I hope we find them before 60 years have passed.

To view a high level Cause Map, click on “Download PDF” above.

Fire Door Falls on Dementia Patient

By Angela Griffith

On November 7, 2013, during renovation taking place at a care home in Moston, Great Britain, staff responded to a cry for help, finding a resident underneath a fire door that had been removed and leaned against a wardrobe during the remodeling work.  The resident suffered a broken hip and died on December 2nd.  The management trust that operated the care home and the renovating firm were both fined under the Health and Safety at Work Act after a Health and Safety Executive (HSE) investigation found that the renovation area, which contained multiple hazards, had been left unlocked the night before.

According to HSE Inspector Laura Moran, “Both firms clearly knew there were vulnerable residents living at the care home but they still allowed the door to what was essentially a building site to be left unlocked on numerous occasions.”  Clearly multiple failures led to the resident’s death.  Diagramming the cause-and-effect relationships related to this issue can help clarify what happened, and offer areas for improvement.

We can perform an analysis of this incident in a Cause Map, or visual root cause analysis.  We begin with the impacted goals.  The patient safety goal was impacted due to the death of the patient.  In addition, the employee safety goal was impacted due to the potential for employee injury.  The fines can be considered an impact to the compliance goal and the patient services goal is impacted due to the insufficient protection provided for residents.

Beginning with an impacted goal and asking “why” questions develops the cause-and-effect relationships.  In this case, the patient death resulted from a broken hip.  The broken hip resulted from the patient being crushed under a fire door.  (It took 3 people to lift the fire door off the patient.)  The patient was crushed under the fire door because the fire door fell and the patient was in the renovation area where the fire door was located.  Both of these causes are required – had the fire door not fallen, the patient would not have been crushed, even if she was in the renovation area.  If the fire door fell but the patient was not present, the patient also would not have been crushed.  When both causes are required to produce an effect, the causes are joined by and “and” on the Cause Map.

The fire door fell as it was leaning against a wardrobe due to the renovation.  The patient, who suffered from dementia, was prone to wandering and was able to access the area under renovation because it had not been locked.  Neither the renovation firm nor the care home staff locked the area, or checked to verify that it was locked.

Other goals can be added as effects in the appropriate locations of the analysis.  For example, the patient services goal was impacted due to the insufficient protection of patients.  This occurred because the renovation area was unlocked and because the hazards in the renovation area.  (Beyond the fire door, the care home staff found exposed wiring, loose boards, and other potential safety hazards.)  The insufficient protection of patients resulted in the fine.  The impact to the employee safety goal was impacted due to the renovation area hazards as well.

Some amount of hazard always exists in construction sites – this is why hard hats are generally required.  It’s also why access to these sites is controlled.  In this case, limiting access to only those that need it was determined to be the best way to protect patients.  Because the previous process for ensuring the area was locked had failed, according to Inspector Moran, “Following the incident, the companies introduced a new procedure which meant workers had to collect and return a key at the start and end of each day, and lock the door when there was no one inside.”

The lessons learned from this tragedy are applicable not only to the specific situation of care homes undergoing renovation but to all those who have a need to protect a vulnerable population or limit access to a hazardous site to ensure safety.  Simple things like making sure doors are locked at the end of the day may save a life.

 

Heavy Metal Toxicity Professor Killed by Mercury Exposure

By Angela Griffith

Professor Karen Wetterhahn knew firsthand how dangerous heavy metals could be.  Her research involved determining the biologic toxicity of heavy metals.  The chemical she was working with on August 14, 1996, was particularly dangerous.  Dimethylmercury, used as a reference standard, is lethal at about 400 mg, a few drops.  This classifies it as “supertoxic”.  When she spilled a few drops on her gloved hand, she assumed the precautions she had taken (the use of disposable latex gloves and a ventilated hood) were adequate.  She was incorrect, but would not know it for quite a while.

It took 149 days before Professor Wetterhahn began to exhibit neurological symptoms, 154 days before she sought care, and 168 days before chelation therapy began.  Chelation therapy involves the use of agents that form chemical bonds with metal ions to form a water-soluble complex, allowing the heavy metal to be excreted from the body.  However, according to a report on Professor Wetterhahn’s death in the New England Journal of Medicine (NEJM), chelation treatment delayed after exposure “is of little or no clinical benefit”.

Professor Wetterhahn became unresponsive on February 12, 1997 and died on June 8.  As a result of her poisoning, more research has been done to better determine the causes that led to her death, as well as determining actions that can reduce the risk of more deaths from mercury poisoning.  We can look at these causes in a Cause Map, or visual root cause analysis.

The death of Professor Wetterhahn was due to accidental dimethylmercury poisoning, which is lethal in just a few drops, and ineffective chelation therapy (which may have been able to reduce the impact had it been administered immediately after exposure).  Due to the latency of neurological symptoms and the belief that protections taken while working with dimethylmercury were adequate, this did not occur.

Based on later research and testing, it was determined that Professor Wetterhahn was exposed through her skin when she dropped a few drops of dimethylmercury on her glove.  The disposable latex gloves she was wearing were later found to result in permeation to the skin in a matter of seconds.    The Material Safety Data Sheet (MSDS), which defines necessary personal protection for working with various chemicals, specified only “wear appropriate chemical-resistant gloves”.  The use of a plastic-laminate chemically-resistant glove was found to result in no permeation after four hours and should be used rather than disposable latex while working with this chemical.

It is also possible that mercury exposure occurred via inhalation. Although Professor Wetterhahn was using a ventilated hood, dimethylmercury is extremely volatile and could have created an inhalation hazard when it was spilled.

Many organizations would be tempted to identify the spill of the dimethylmercury as the root cause and end the investigation there.   However, basing personnel safety solely on attempting to prevent spills does not provide adequate protection.  In this case, the risks of using dimethylmercury were found to be so high that an alternative is recommended unless absolutely necessary.  If the use of the supertoxic compound is found to be essential, very specific personal protection equipment is called for as well as seeking treatment immediately after possible exposure.

In the NEJM report, the authors state Before she lapsed into a vegetative state, the patient requested that her case be presented to the general medical community, to scientists working with mercury, and to toxicologists, in the hope of improving the recognition, treatment, and prevention of future cases of mercury poisoning.”   By examining all the causes and possible solutions, it is hoped that all chemical work can be made safer, in honor of Professor Wetterhahn.

To view the Outline, Cause Map and timeline of this issue, please click on “Download PDF” above.

Alleged Radiology Misreading Results in Removal of Cancer Patient’s Healthy Kidney

By Angela Griffith

On January 17, 2013, a radiologist discussed the results of a CT scan with an urologist.  The CT scans identified cancer in the kidney of an urologist’s patient.  Two months later, the patient underwent surgery to remove the kidney.  The kidney was examined by a pathologist, who declared it cancer-free.  The wrong kidney had been removed, allegedly due to a misidentification by the radiologist.

Wrong-site surgeries like this one can lead to severe patient safety consequences, as well as severe financial and regulatory consequences for the doctors and healthcare facilities involved.  This is why surgery performed on the wrong body part has been identified as a “never event“, or an event that should never occur in a healthcare facility.

Even with this designation and the known seriousness of the issues, wrong-site surgeries continue to occur.  The Joint Commission estimates that the prevalence of wrong-site surgeries in the United States is as high as 40 per week.

Clearly, action must be taken to reduce the risk of wrong-site surgeries.  To identify areas of potential improvement, it can help to look at an example of an actual case of wrong-site surgery to determine lessons learned.  We will examine the case of the wrong kidney being removed as an example of issues that can lead to wrong-site surgeries using the Cause Mapping method of root cause analysis.

It’s important to identify the impacts to the goals as a result of an incident.  In this case, the patient safety goal was clearly impacted as the patient now has only 3/4 of a kidney remaining, with the potential to cause serious health impacts.  (A portion of the cancerous kidney was removed in a later operation.)  The compliance goal is impacted because of the occurrence of a “never event” as discussed above.  The patient services goal is impacted due to the removal of the wrong (healthy) kidney.  The radiologist and urologist involved in the issue have been sued for more than $1 million as a result of the issue.  If all these issues received similar lawsuits, the costs to the health system would be over $2B a year.

Once the impacts to the goals are identified, asking “why” questions develops the cause-and-effect relationships that led to the issue.  In this case, the removal of the wrong kidney is alleged to have resulted from the radiologist misreading the CT scan that identified the kidney with cancer and passing that information on to the urologist who performed the surgery.  Clearly the urologist’s physical exam (if any) did not adequately determine the site of the cancer.

To better understand the steps that led to the surgery, they can be diagrammed in a Process Map.  A Process Map lays out a process in much the same way that a Cause Map visually lays out cause-and-effect relationships.  A very high level overview of the process used in this case is shown on the downloadable PDF.  What’s important to note is that an incorrect reading of a CT scan or other diagnostic tool propagates through the process.  With no second opinions or double checks built in, the diagnosis of cancer in the left kidney was the only information the urologist had to determine the operating site.

There are of course other errors in the surgical preparation procedure that can also cause wrong-site surgeries.  (Many of these errors are identified in our proactive write-up on wrong-site surgeries.)  As stated by Mark R. Chassin, M.D., President of The Joint Commission, “Wrong site surgery events occur basically because none of the processes that we use in taking care of patients is perfect.”  Equally important is that the people performing the processes are not perfect.  Although both processes and people’s performance can be improved, it will never reach perfection.  For this reason, adding double checks and second opinions into processes is essential to reduce the risk of the one mistake resulting in a devastating patient safety impact.  In this case, having a second opinion on the CT scan, or having the physician re-identify the area with a physical exam prior to surgery (if possible) may have identified the error prior to removal of a healthy kidney.

View the Cause Map and process map by clicking on “Download PDF” above.

“Artificial Pancreas” May Dramatically Improve Management of Type 1 Diabetes

By Kim Smiley

As many as 3 million Americans have type 1 diabetes and for many managing the autoimmune disease requires constant vigilance.  Patients have to carefully monitor what they eat and their blood sugar levels, often pricking their fingers and injecting insulin multiple times a day.  The number of people diagnosed with type 1 diabetes has been increasing, but there is some good news.  There is no cure for type 1 diabetes, but a new device, an artificial pancreas, may make managing the disease significantly simpler.

Type 1 diabetes is caused when the immune systems attacks insulin-producing cells in the pancreas so the body can no longer produce adequate insulin.  Insulin is needed because it works to allow sugar to enter cells where it is used for energy, reducing the levels of sugar in the blood stream.  Sugar builds up in the blood when food is consumed and from natural processes in the body.  Without enough insulin, blood sugar levels will continue to increase.  High blood sugar can damage major organs and can have significant impacts on long-term health.  Low blood sugar is also dangerous and can quickly become a life-threatening emergency so patients with type 1 diabetes are constantly working to keep blood sugar within acceptable levels.

The artificial pancreas works by monitoring blood sugar levels every 5 minutes and using two pumps to deliver two different hormones (insulin to lower blood sugar levels and glucagon to raise blood sugar) as needed with minimum intervention required by the user.  The current version of the artificial pancreas consists of three parts (two small pumps and iPhone contacted to a continuous glucose monitor) but there are plans to simplify the device in the future.  The components connect to three small needles that are inserted in the patient to allow blood sugar levels to be monitored.  Insulin pumps currently used by many type 1 diabetics can only inject insulin and require more input from the user, so the artificial pancreas is a significant improvement over currently available technology.

The artificial pancreas is still in the development stage and needs additional testing and modification prior to becoming widely available for patient use.  The first test was done using about 50 patients (20 adults and 32 teenagers) who wore the new device for 5 days.  The results were very promising, but more testing will need to be done. During the 5-day test, the patients had lower blood sugar levels overall and the device simplified management of the disease.  Researchers reported that the patients didn’t want to return the devices because they worked so well. The next step is to have patients use the device for a longer time period.  It’s essential to ensure that the device is very robust, because the consequences can be dire if it fails.  Once the design is finalized, the hope is to seek FDA approval and have the artificial pancreas available in about 3 years.

To view a Cause Map of this issue, click on “Download PDF” above.

5.5 Million Cases of Norovirus are Spread Via Food Each Year

By Kim Smiley

Norovirus outbreaks on cruise ships may make exciting headlines, but the reality is that only one percent of norovirus outbreaks occur on the high seas.  About 20 million people in the US are sickened by noroviruses in the US each year and one of the most common transmission paths is via food.  Food-borne norovirus is estimated to be responsible for 5.5 million cases of norovirus annually in the US.

A Cause Map, a visual method for performing a root cause analysis, can be used to analyze this issue.  The first step in the Cause Mapping process is to determine how an issue impacts the overall goals and then the Cause Map is built by asking “why” questions to visually lay out the cause-and-effect relationships.  In this example, we’ll focus on the safety goal since it is clearly impacted by 5.5 million cases of norovirus transmitted via food.

So why are people getting norovirus from food?  This is happening because they are consuming contaminated food, predominantly at restaurants or catered events.  The food becomes contaminated when a food worker’s hands are contaminated by norovirus and they touch food, particularly food that is ready to serve and won’t be cooked prior to consumption.  (Disclaimer: You may want to stop reading here if you are eating or thinking about going to out to eat soon.)

For those unfamiliar with the illness, norovirus is basically a gastrointestinal nightmare that can cause the human body to do very messy things.  If a food service worker is ill, the virus can get on their hands, especially after using the bathroom.  According to a Centers for Disease Control and Prevention (CDC) report, the transmission of food-borne norovirus is “primarily via the fecal-oral route.”  And that is more than enough said about that.

It is also worth asking why food workers are at work if they are under the weather.  In the US, few food service workers get paid sick leave so they may show up at work sick because they are concerned about the loss of income and the impact on their jobs.  It’s also important to ensure that workers understand the importance of good hygiene and have access to both water and soap and time to effectively wash their hands.

The final step in the Cause Mapping process is to develop solutions to reduce the risk of the problem recurring.  The solutions to this problem are both simple in concept and difficult to effectively implement.  Ideally, food workers should stay home when they are ill and for at least 48 hours afterwards, but this is much easier said than done for many people.  Food workers should also wash their hands after using the bathroom and before handling any food, but it can be difficult to enforce the policy because employers and managers aren’t (and shouldn’t be) closely monitoring what happens during bathroom breaks.

To view a high level Cause Map of this issue, click on “Download PDF” above.

Gamma Camera Collapse Kills Patient

By Angela Griffith

On June 5, 2013, a nuclear medicine scanner was being used for a diagnostic procedure at a New York Veterans Affairs (VA) medical center when the gamma camera collapsed on a patient, causing his death.  This issue can be examined in a Cause Map, or visual root cause analysis, in order to determine both the impact to the organization’s goals as well as the causes of the incident.

In this case, multiple goals were impacted, the first and foremost of which is the death of a patient.  This is an impact to the patient safety goal.  Had the camera collapsed at a different time, it could have also injured an employee, causing an impact to the employee safety goal as well.  The death of a patient due to a medical device that functions other than designed is a “Never Event“, or an event that should never happen in a medical facility.  The scanner collapse on a patient clearly does not meet the goals for patient services.  The property goal is impacted due to potential damage to the scanner. (None of the publicly released reports specified how much damage, if any, was caused to the scanner and camera.)  The scanners of this type from this manufacturer were recalled shortly after this incident, impacting the operations goal and necessitating inspection and/or maintenance activities provided by the manufacturer, an impact to the labor time goal.

Investigation conducted shortly after this patient’s death determined the collapse was caused by loose bolts.  The machines were quickly subject to a Class 1 recall with the FDA.  Sites with the recalled equipment were told to discontinue use until inspections and, if needed, preventive maintenance could be performed by the manufacturer.  Said the manufacturer’s spokesperson, “If no issue is found with the support mechanism fasteners, the site can resume use of the device. If an issue with the support mechanism fasteners is found on a system, the GEHC Field Engineer will coordinate the replacement of impacted parts, and ensure that the system is operating appropriately and meets all specifications.”

Publicly released information about the incident has not specified who was responsible for the preventive maintenance that may have determined the need for tightening the bolts.  However, inspection and maintenance costs were covered by the manufacturer of the devices.

Sites that are using the affected models should have been notified and should stop use until the recommendations of the recall are met.  Although details of broader solutions were not available, both the manufacturer of the devices and the healthcare facilities using them will surely take a look at the preventive maintenance schedule to decrease the risk of patient injury from this type of event.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.

Study Finds Bacteria Can Live on Airplane Surfaces for Days

By Kim Smiley

With many bodies packed into a tight space and seemingly stale air, airplanes tend to bring out the inner germaphobe in many of us.  And the latest research, especially if you just read the headlines, isn’t going to help. Researchers at the University of Auburn found that Methicillin-resistant Staphylococcus aureus (commonly known as MRSA) and E. Coli can live for days on airplane surfaces.

The experiment involved sterilizing six surfaces found on airplanes (seat pocket, arm rest, leather seat, window shade, tray table and toilet handle), introducing MRSA and E. Coli bacteria to them and then measuring how long the bacteria survived.  Typical conditions inside an airplane were stimulated and the bacteria were suspended in three different solutions (saline, simulated seat and simulated saliva) to replicated the environment inside an airplane. The survival times ranged from 8 to 2 days.  This is a little scary, especially since an estimated 1-2 percent of people in the US may be carriers of these dangerous bacteria.

The good news, and there is good news, is that the surfaces where the bacteria lived the longest, the more porous surfaces such as the seat pocket, are the least likely surfaces to actually spread the contamination.  The study also didn’t look into how much bacteria remained after the typical cleaning  by airlines between flights, but the researchers plan to look into this in the future.

So what can you do to reduce the risk of illness if you have plans to travel on an airplane soon?  The simplest thing you can do to protect yourself is to frequently wash your hands with soap or use hand sanitizer as well as avoid touching your face as much as possible.  If you feel the need to take additional precautions, you can clean the areas around your seat with a disinfectant when you board the plane.

Airline cleaning procedures can also significantly impact the spread of illness.  So the question is, how much do you trust the thoroughness of the cleaning performed by the airline?  I think I may invest in a travel-size hand sanitizer before my next flight.

To see a high level Cause Map of this issue, click on “Download PDF” above.

Lethal injection fails to quickly kill prisoner

By Angela Griffith

While the use of the death penalty remains highly controversial, there is general agreement that if it is used, it should be humane.  The execution of a prisoner in Oklahoma on April 29, 2014 did not meet those standards.  The inmate died 43 minutes after the drugs were injected.  (Typically death takes 5-6 minutes after injection.)  According to Jay Carney, the White House Spokesperson, “We have a fundamental standard in this country that even when the death penalty is justified, it must be carried out humanely – and I think everyone would recognize that this case fell short of that standard.”

The details surrounding this case can be captured in a Cause Map, or visual root cause analysis, to examine the causes and effects of the issue.

The problem being evaluated is the botched execution of an inmate in the Oklahoma State Penitentiary. The execution began at 6:23 pm on April 29, 2014.  An important difference in this execution, compared to other executions, is that it was the first time the state had used the drug midazolam as part of the three-drug injection protocol.  The protocol, when originally developed in 1977, called for sodium thiopental, followed by pancuronium bromide and potassium chloride.

The safety goal was impacted in this case because of the failed execution.  The public service goal can be considered to be impacted as the execution was called off (after all three drugs were administered; the prisoner later died of a heart attack.)  The schedule goal is impacted because all future executions have been called off.  The state planned a two-week postponement of the next execution (scheduled for later the same day) in order for a review of this investigation to be completed, but at the time of this writing, that execution has not yet been scheduled.  Executions across the country have been appealed or stayed and none have taken place since April 29th.  The labor/ time goal is also impacted due to the investigation into the execution, which has not yet been published.

These goals were impacted due to the failure of the lethal injection.  The process intended to be used for this lethal injection is detailed on the downloadable PDF.  However, from the start things didn’t go smoothly.  Instead of using two IVs, one in each arm, only one IV was able to be connected, in the patient’s groin.  Because sodium thiopental is no longer available (drug companies will no longer provide it for use in lethal injections), the drug midazolam was used instead.  However, the protocol for using that drug is disputed.  In Florida, five times the amount of midazolam is used.  In Oklahoma, midazolam is used along with hydromorphone.  Because of the debate about lethal injection, most states don’t divulge their suppliers, so the efficacy of the drugs used cannot be verified.  In addition, there is generally at least one doctor present to oversee the executions, but these doctors are not usually identified and may not participate in the actual administration of the drugs because many medical organizations ban doctors from participating on ethical grounds.

At this point, it’s unclear what will happen at future executions.  The investigative report being prepared by the state of Oklahoma may give some suggestions as to how to make lethal injections more humane in the future, or this may tilt the scales towards ending lethal injection, or executions altogether.

To view the Outline, Cause Map, and Process Map, please click “Download PDF” above.